The evidence on the effectiveness of management for malignant pleural effusion: a systematic review.

The aim of this study was to review systematically the available evidence on pleurodesis for malignant effusion, focusing on the choice of the agents, route of delivery and other strategies to improve outcomes. Four electronic databases (MEDLINE, EMBASE, Web of Science and Cochrane Controlled Trials Register) were searched, reference lists checked and letters requesting details of unpublished trials and data sent to authors of previous trials. Studies of malignant pleural effusion in humans were selected with no language restrictions applied. Criteria for randomised clinical trial (RCT) eligibility were random allocation of patients and non-concurrent use of another experimental medication or device. Methodological quality evaluation of the trials was based on randomisation, blinding, allocation concealment and intention to treat analysis. A random effect model was used to combine the relative risk estimates of the treatment effects whenever pooling for an overall effect was considered appropriate. Forty-six RCTs with a total of 2053 patients with malignant pleural effusions were reviewed for effectiveness of pleurodesis. Talc tended to be associated with fewer recurrences when compared to bleomycin (RR, 0.64; 95% CI, 0.34-1.20) and, with more uncertainty, to tetracycline (RR, 0.50; 95% CI, 0.06-4.42). Tetracycline (or doxycycline) was not superior to bleomycin (RR, 0.92; 95% CI, 0.61-1.38). When compared with bedside talc slurry, thoracoscopic talc insufflation was associated with a reduction in recurrence (RR, 0.21; 95% CI, 0.05-0.93). Strategies such as rolling the patient after instillation of the sclerosing agent, protracted drainage of the effusion and use of larger chest tubes were not found to have any substantial advantages. Talc appears to be effective and should be the agent of choice for pleurodesis. Thoracoscopic talc insufflation is associated with fewer recurrences of effusions compared with bedside talc slurry, but this is based on two small studies. Where thoracoscopy is unavailable bedside talc pleurodesis has a high success rate and is the next best option

Quality of life after aortic valve replacement with tissue and mechanical implants

AbstractObjectivesWe sought to determine whether changes in quality of life at 18 months following aortic valve replacement differ depending on the use of tissue valves or mechanical valves.MethodsWe prospectively studied 73 patients with tissue valve replacements and 53 patients with mechanical valve replacements performed from April 1998 through March 1999 at Yale-New Haven Hospital. Quality of life was measured at baseline and at 18 months using the Medical Outcomes Trust Short Form 36-Item Health Survey.ResultsBaseline unadjusted mean quality-of-life scores were lower in tissue valve recipients than in mechanical valve recipients and, for both groups, were generally lower than US population norms. At 18 months postoperatively, quality-of-life scores were greatly improved in both groups and were comparable to population norms (ie, within one-half a standard deviation). After adjusting for baseline quality of life, age, and other prognostic factors in an analysis of covariance, improvements in quality-of-life scores for tissue valve recipients versus mechanical valve recipients were similar. Of 10 (8 domains and 2 summary) scales examined, the only significant difference between the 2 groups was for the improvement in role limitations due to physical problems (Role Physical), which was more favorable in patients with mechanical valve implants (P = .04).ConclusionsThe use of tissue valve implants versus mechanical valve implants has little influence on improvement in quality of life at 18 months following aortic valve replacement. Thus, decisions about whether to choose a tissue valve or mechanical valve implant should depend upon other factors such as rates of complications and differences in the life span of the implants

Improving clinical outcomes in coronary artery bypass graft surgery.

PURPOSE: Medical decisions are often made based on personal experience or on limited clinical trial information. Results from systematic reviews of clinical trials, however, provide a more thorough understanding of available data and can foster evidence-based decision making. Data from a recent systematic review and meta-analysis of clinical outcomes after aprotinin treatment during coronary artery bypass graft (CABG) surgery have recently been published. This analysis was performed to further address concerns that aprotinin safety often outweighs the well-established transfusion reduction benefits. SUMMARY: Data from placebo controlled, randomized, aprotinin trials published in MEDLINE, EMBASE, and PHARMLINE were analyzed. Relative risk (RR) and 95% confidence intervals (CI) were calculated for mortality, myocardial infarction, renal failure, stroke, atrial fibrillation, and blood transfusion. Fixed effect or random effect models were used. Homogeneity was tested across studies using chi(2) statistics and i-square (I(2)) values. Analysis of data from 35 placebo controlled trials (n = 3,887) confirms that aprotinin, when compared to placebo, reduces transfusion requirements (RR, 0.61; 95% CI, 0.58-0.66). Risks of mortality (RR, 0.96; 95% CI, 0.65-1.40), myocardial infarction (RR, 0.85; 95% CI, 0.63-1.14) and renal failure (RR, 1.01; 95% CI, 0.55-1.83) were neither increased nor decreased with aprotinin treatment. Aprotinin treatment was, however, associated with a reduced risk of stroke (RR, 0.53; 95% CI, 0.31-0.90) and a trend toward a reduced incidence of atrial fibrillation (RR, 0.90, 95% CI, 0.78-1.03). CONCLUSION: Results from this systematic review and meta-analysis of randomized controlled trials in CABG surgery patients have shown that aprotinin was associated with a reduction in the need for blood transfusion, but was not associated with an increase in mortality, myocardial infarction, or renal failure risk. Evidence also suggests that aprotinin was associated with a reduced stroke risk and a trend toward a reduced incidence of atrial fibrillation

Improving depiction of benefits and harms: analyses of studies of well-known therapeutics and review of high-impact medical journals.

The issues of weighing benefits and harms and of shared decision-making have become increasingly important in recent years. There is limited knowledge and lack of adequate data on the most transparent method of communicating the information. In this article we discuss examples of communicating benefits and harms for well-known therapeutics, illustrating that relative risk estimates are not helpful for communicating the chance of experiencing adverse events. In addition, we show that asymmetric presentation of the data for benefits and harms is likely to bias toward showing greater benefits and diminishing the importance of the harms (or vice versa). We also present preliminary results of a brief review of high-impact medical journals that show limitations of current systematic reviews. In the review we found that every second published study does not discuss frequency data and 1 in 3 studies that report information on both benefits and harms does not report information in the same metric. We conclude that consistently depicting benefit and harm information in frequencies can substantially improve the communication of benefits and harms. Investigators should be requested to provide frequency data along with relative risk information in the publication of their scientific findings. Currently, even in the highest impact medical journals, evidence of benefits and harms is not consistently presented in ways that facilitate accurate interpretation

Recursive partitioning-based preoperative risk stratification for atrial fibrillation after coronary artery bypass surgery.

BACKGROUND: Knowledge of the risk of atrial fibrillation (AF) for patients undergoing coronary artery bypass graft surgery (CABG) can guide decisions about prophylactic therapy. Accordingly, we sought to use tree-based methods to stratify patients into groups that will have similar risk of AF after CABG and informed decision making regarding aggressive prophylaxis of AF. METHODS: We studied 1209 consecutive patients with isolated CABG performed in 1998-1999 at Yale-New Haven Hospital. Patients with preoperative AF were excluded. Tree-based analysis was carried out to stratify patients into similar groups regarding the risk of AF. Relative risks (RRs) and 95% CIs were calculated at each level of stratification. RESULTS: Age was the most important variable. The importance of other risk factors seemed to be different for younger and older patients. Although in the younger age group ( or =70 years), nothing or only ejection fraction <40% (RR 1.31, 95% CI 1.08-1.59) was important. In the highest-risk group, AF occurrence was 55% and, in the lowest-risk group, it was 10%. In the low-risk groups, aggressive prophylaxis may not be justified in light of the smaller number of events that would be prevented, possible adverse events, and costs. CONCLUSION: Age and variables related to heart disease severity are predictors of AF. The tree-based method may be a useful tool for clinicians who seek to determine who is more or less likely to benefit from aggressive arrhythmia prophylaxis

Variation in use of video assisted thoracic surgery in the United Kingdom

Video assisted thoracic surgery (VATS) is a minimally invasive technique for the diagnosis and treatment of lung and pleural disease. Thoracotomy is replaced by up to three small incisions from 0.5 to 2.0 cm long and well lit video images are displayed on large screens, allowing the surgeon, assistants, and students a view. Variation in the use of medical procedures cannot be fully explained by the prevalence of the disease in question or health characteristics of populations. The willingness of the surgeon to provide a procedure, rather than its appropriateness for the patient, may explain a substantial variation in practice. In our companion paper in this issue we systematically reviewed the evidence for VATS for pneumothorax surgery, minor resections, and lobectomy. Here we determine variation in the use of this procedure in UK practice